Transcript Postsplenectomy sepsis clinical features, management and prevention

Postsplenectomy sepsis
clinical features, management and prevention
Report by Ri劉有文/VS韓吟宜
Introduction
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PSS(Postsplenectomy sepsis)
Fulminant sepsis syndrome
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usually due to S.pneumoniae
Pateint with impaired spleen function or s/p
splenectomy both have risk
Role of spleen
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The largest lymphoid organ
Filter senescent, rigid RBCs
Ingesting circulating bacteria
Production of antibodies
Common causes of theraputic
splenectomy
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Hemolytic anemia
Thrombocytopenia
Malignancy
Hypersplenism
Splenic trauma
Common causes of impaired
spleen function
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Hemoglobinopathy
Hemolysis
Congenital asplenia
Collagen vascular diseases
Allogenic bone marrow transplantation
Incidence
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Children: 1/175 patient years
Adults: 1/400~500 patient years
Highest risk at first few years
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1/3 at first year
1/2 at first 2 years
However, 1/3 after first 5 years
Can happen even 20 years after splenectomy
Common pathogens
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Encapsulated pathogen
Streptococcus pneumoniae(50~60 %)
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No particular serotype is more common
Haemophilus influezae(20~30 %)
Neisseria spp.(10~20 %)
Other uncommon pathogens:
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Capnocytophaga canimorsus
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Common flora in oral cavity of dogs and cats
Bordetella holmesii
Clinical manifestations
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Fever
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Bacteremia
Coagulopathy
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Cough, dyspnea, respiratory failure
GI symptoms
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Headache, neck stiffness, seizure
Respiratory symptoms
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Purpura, petechiae
Meningitis
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Any fever must be viewed as possible PSS
Nausea, vomiting, diarrhea, GI bleeding
Shock
LAB
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CBC
Blood smear
DIC profile
Lumbar puncture
CXR
Blood culture
Management
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Braod-spectrum antibiotics
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Based on expert opinion
Must cover:
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General suggestion
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penicillin-resistant pneucoccus
beta-lactamase producing H.influenzae
Ceftriaxone + Vancomycin
Levofloxacin + Vancomycin
Life-support measures
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H/D or CVVH for ARF
Ventilator
Inotropic agents
Fluid
Prevention
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Avoid unnecessary splenectomy
Immunization
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Timing
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Pneumococcal vaccine
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14 days before splenectomy
14 days after splenectomy (not immediately)
PPV-23 for adults
PCPV-7 for children and some adults
Haemophilus B vaccine
Meningococcal vaccine
Re-immunization
Other vaccines: influenza vaccine
Prevention
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Antibiotic prophylaxis
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Daily penicillin
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Abx for fever
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Reduce incidence by half
Reduce mortality by 80 percents
Life-long or 3~5years?
Post PSS patients
On hand
Empirical: Augmentin, Cefuroxine, fluoroquinolones
When fever, Take the drug and go to doctor without
delay
Abx for dental procedures
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Not recommended for no obvious advantage
Summary
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Be aware
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Treatment in time
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Any fever may be possible PSS
Empirical abx
Supportive care
Pervention
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Vaccine
Daily and On hand abx